Collaborative Care Guidelines for Perioperative Nurses

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Collaborative Care Guidelines

for Perioperative Nurses

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Licensed Practical Nurses of Nova Scotia.

Document Accountability: Nova Scotia Perioperative Directors and Managers Version 18 – Final Draft, Jan 10, 2013

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Overview . . . 1

Purpose of the Document . . . 3

General Assumptions . . . 4

Guiding Principles for Interprofessional Practice . . . 5

Scope of Practice . . . 7

Phases of the Perioperative Experience . . . 9

The Preoperative Phase . . . 10

The Intraoperative Phase . . . 12

The Postoperative Phase . . . 17

Definitions / Glossary . . . 19

References . . . 23

Appendix A • Circulating Role Psychomotor Skills . . . 25

Appendix B • Scrub Role Psychomotor Skills . . . 40

Appendix C • Effect of Types and Techniques of

Sedation and General Anesthesia . . . 53

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The Model of Care Initiative would like to acknowledge the sub group of the MOCINS Peri-operative Project Working Group and the College of Registered Nurses of Nova Scotia and the College of Licensed Practical Nurses of Nova Scotia for their contributions to the development of these guidelines.

DHA 3 Cheryl Ernst

Sharlene Van Roessel

DHA 6 Priscilla Sharkey

DHA 7 Cathy Ferguson

DHA 8 Shaunna Snow

DHA 9 Cathy Saunders Cindy Fulmore Karen Strickland

IWK Cathy Shea

Heather Simmons

CLPNNS Doug Bungay CRNNS Julie Gregg

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Collaborative Care Guidelines • Overview

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Overview

Across Canada the practice of both regis-tered nurses (RN) and licensed practical nurses (LPN) continues to evolve in order to meet the health needs of Canadians. In Nova Scotia, with the introduction of the Model of Care Initiative in Nova Scotia (MOCINS), all nurses (RNs and LPNs) have been encour-aged to optimize their roles and practice to the full extent of their individual level of com-petency, based on their education and expe-rience. This evolution requires not only RNs and LPNs, but also health care managers, and the health care team to better understand the roles and responsibilities of each type of health care provider so that they are more ef-fectively utilized in an ever-changing health care environment.

One of the objectives of the Model of Care Initiative in 2012/13 is to expand the provin-cial implementation of the Collaborative Care Model to perioperative settings. The Collab-orative Care Model is a conceptual frame-work that is used to guide local implementa-tion of new care delivery models. The goal of the model is to provide high quality, safe client care in hospitals more efficiently by making the best use of staff knowledge, skills, and competencies, improving processes, and better supporting access to information and modern technology. Within the discipline of nursing, in the perioperative setting, optimi-zation of the LPN role, when appropriate, will assist in meeting this goal.

The decision to optimize the role of the LPN as part of a collaborative team in the periopera-tive setting is based on a clear understanding of the differences in educational preparation, competencies, and scope of practice of both types of nurses. The perioperative services area can be a complex and unpredictable en-vironment. The more complex and unpredict-able the environment the higher the category of care provider needed to provide the full range of potential care requirements, assess changes, and re-establish priorities. While RNs and LPNs may be educated similarly in terms of performing specific tasks and func-tions, the depth and breadth of education with respect to knowledge and clinical judg-ment is very different.

According to the Guidelines: Effective

Utiliza-tion of RNs and LPNs in a Collaborative Prac-tice Environment (2012), Registered Nurses,

Licensed Practical Nurses and managers must be aware that effective decisions to match client needs with either a registered nurse or a licensed practical nurse, should be based on the following equally important factors: client acuity, scope of practice of the nurs-ing role, nurses’ own individual competence, scope of employment and practice environ-ment (e.g. number of nursing resources, al-lied health team members and organizational policies).

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Increasingly there is a need to demonstrate how nurses provide care, the interventions or actions used by nurses to influence client health outcomes, and the appropriate mix of nursing staff necessary to provide safe com-petent care (White & Pringle, 2005). Nursing-outcomes research attempts to establish which nursing interventions contribute to desired outcomes and are cost effective; and make nursing interventions understandable to other professions, administrators and cli-ents (Schreb, 2001). Such research helps an-swer the question “is the right person provid-ing the right care at the right time?”

Current nursing literature supports the fact that the practice of registered nurses increas-es positive health outcomincreas-es in the form of decreased complications and an increase in client safety. At present there is a lack of re-search devoted to the contributions made by licensed practical nurses to health outcomes.

Based on the best available current evidence, decision makers need to consider the key dif-ferences in the fundamental values of the professions, knowledge base, critical think-ing skills, and the inherent qualities of RNs and LPNs to ensure the appropriate utiliza-tion of each of their services in the practice setting.

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Collaborative Care Guidelines • Purpose of the Document

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Purpose

of the Document

The purpose of this document is to pro-vide guidance for the effective utiliza-tion of RNs and LPNs within a collab-orative practice team across the client’s perioperative experience in Nova Scotia. The three phases of the perioperative experi-ence are as follows:

• preoperative • intra operative • post-operative.

This document has been organized starting with an overview of assumptions and prin-ciples that span all three phases after which each phase is highlighted, denoting any phase specific considerations and guidelines for the effective utilization of RNs and LPNs in perioperative settings.

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General Assumptions

In health care, all health professionals are ex-pected to work collaboratively with each other and in partnership with the person receiving care. Effective inter-professional collaborative practice is centered on the needs of clients as they partner with the most appropriate health professionals in order to meet their healthcare needs (Health Professions Regulatory Network, 2008).

The College of Registered Nurses of Nova Sco-tia (CRNNS) & College of Licensed Practical Nurses of Nova Scotia (CLPNNS) Guidelines:

Ef-fective Utilization of RNs and LPNs in a Collab-orative Practice Environment (2012) outline a

number of assumptions to guide the decision making required for the most effective utiliza-tion of RNs and LPNs in any collaborative prac-tice setting. They are as follows:

1 Staff mix decisions are based on the

results of an assessment of the client population served, and their overall health needs. A care delivery model is designed so that the right staff mix is in place to meet the health outcomes of the client population served.

2 There are two categories of nurses in Nova

Scotia—registered nurses (RNs), which include nurse practitioners (NPs), and licensed practical nurses (LPNs).

3 All nurses practice in a manner that is

consistent with legislation, their standards for practice, codes of ethics, and scopes of practice.

4 All nurses are accountable for their

deci-sions, actions and the consequences of those actions. Nurses are not accountable for the actions and decisions of other nurses or care providers in situations in which they have no way of knowing about those actions.

5 RNs and LPNs study from the same body

of nursing knowledge. LPNs have core-nursing knowledge. The knowledge base of the RN is broader, in-depth, and more comprehensive. As a result, the level of autonomous practice of the RN differs from that of the LPN.

6 Licensed practical nurses are educated

to practice independently and manage predictable clients who have less complex care needs via an established plan of care. When LPNs provide care to clients with more complex needs and unpredictable health outcomes, they must consult with an RN (or other appropriate health care provider).

7 RNs are educated to provide all levels of

nursing care whether caring for stable clients with predictable outcomes or working with clients with unpredictable outcomes and whose health needs are acute, complex and rapidly changing.

8 All nurses, throughout their careers, are

expected to continually enhance their learning by adding to their foundational knowledge base and becoming expert in a particular area of practice. A continuing competence program (CCP) is one strategy that can be used to integrate learning into nursing practice.

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Collaborative Care Guidelines • Guiding Principles for Interprofessional Practice

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Guiding Principles

for Interprofessional Practice

Within the interprofessional perioperative collaborative care team, the following prin-ciples apply. (CRNNS & CLPNNS, 2012)

Focus On and

Engagement of Clients

Clients are integral members of a collabora-tive practice health care team and when ac-tively engaged in managing their own health become part of the decision-making team rather than passive recipients of healthcare. Effective communication between team members and clients leads to improved client satisfaction and better client outcomes.

Population Health

A population health approach uses the de-terminants of health to address client needs. Clients and health professionals work togeth-er in dettogeth-ermining how clients can effectively promote their health and/or manage their illnesses.

Trust and Respect

Members of a collaborative practice health care team must have a basic understanding and respect for each other’s roles and trust that all team members will consult and col-laborate appropriately when clients’ needs are beyond their scope of practice.

Effective Communications

Effective communication is an essential com-ponent of collaborative practice and central to a common philosophy of care and knowl-edge exchange. The team must not only un-derstand the concerns, perspectives, and experiences of the client and family, but also their environment and combine this under-standing with the capacity to communicate this to others, so that positive client out-comes can emerge.

Consultation

Intra-professional collaboration most often occurs in the clinical setting and requires both time and resources for efficient and ef-fective consultation, as often as necessary, to meet client needs. Consultation involves seeking advice or information from a more experienced or knowledgeable nurse or an-other health care professional. The complex-ity of client care needs, the nurse’s compe-tence and resources available in the practice setting, influence the amount of consultation required. During a consultation, nurses clarify their reasons for consulting and determine an appropriate course of action. Unless care is transferred, the nurse who sought consul-tation is still accountable for the client’s care.

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Consultation results in one of the following actions:

a the nurse receives advice and continues

to care for the client;

b the nurse transfers an aspect of care

to the consultant and,

c the nurse transfers all care to the

consultant. When any care is transferred from one nurse to another, the

accountability for that care is also transferred.

When an assignment involves the expecta-tion of consultaexpecta-tion, nurses must assess that the required consultative resources are avail-able. This means managers have an account-ability to ensure resources such as policies, procedures and well-understood role de-scriptions are in place to support staff utili-zation decisions and the time and resources (standardized assessment tools, established plan of care and appropriate staff-mix) need-ed for consultation, as often as necessary, to meet client needs.

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Collaborative Care Guidelines • Scope of Practice

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Scope of Practice

The overall scope of practice for the profes-sion of nursing and the profesprofes-sion of practi-cal nursing sets the outer limits of practice for all members. The scope of practice of an individual RN or LPN may be limited by edu-cation, experience, and the authority given to that particular nurse to perform all of the functions outlined within the definition of the practice of nursing and the practice of practical nursing. Scope of practice for the perioperative LPN can be found in section Z: Perioperative Specialty of Competency Profile

CLPNNS (2012).

The decision to match client needs with ei-ther a registered nurse or a licensed practi-cal nurse focuses on three factors of equal importance—the client, the scope of prac-tice of the nurse, and the environment. A description of these three factors is located within the model described in the document

Guidelines: Effective Utilization of RNs and LPNs in a Collaborative Practice Environment, 2012.

The following areas are being optimized within the RN scope of practice:

• The RN completes an initial plan of care based on a comprehensive nursing

assessment (including the determinants of health that influence client health outcomes) and establishes the complexity of client condition.

• The RN ensures each client has a nursing plan of care that identifies priority problems, targets outcomes and specifies nursing interventions.

• The RN determines the appropriate care provider by analyzing the overall plan of care and taking into consideration the client, nurse and environmental factors. • The RN must be available to collaborate with the LPN when the LPN is providing care

to a client whose health outcome is less stable and/or less predictable.

• The RN serves as the coordinator of care ensuring that the client care experience is coordinated and integrated within an inter professional model of care.

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The following areas are being optimized within the LPN scope of practice:

• The LPN participates in the development of the initial plan of care.

• The LPN performs ongoing nursing assessment of clients to ensure they respond to interventions as expected.

• The LPN implements client specific interventions that are both entry-level and beyond entry-level competencies.

• The LPN can enact interventions that they are competent to perform - whether the care decision is autonomous, collaborative or solely made by the RN.

• The LPN works in collaboration with the RN to make clinical decisions as client needs increase in intensity.

• The LPN adds or deletes nursing actions / interventions as long as the client is achieving expected outcomes.

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Collaborative Care Guidelines • Phases of the Perioperative Experience

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Phases of the

Perioperative Experience

This section provides phase specific guidance

to support effective utilization of nursing roles.

The three phases of the

perioperative experience are

Preoperative ... 10

Intraoperative ... 12

Post-operative ... 17

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The Preoperative Phase

For the purposes of this document the pre-operative phase will include all areas where perioperative data is collected prior to sur-gery. The surgical experience begins in the physician/surgeon’s office or clinic. Depend-ing on the facility the modes of data collection and the availability of supports may vary but the principles remain constant. Data collec-tion may be, but is not limited to the follow-ing hospital documents: consults, consents, client health assessment questionnaires, admission data bases, history and physicals, pharmacy medication reconciliation, and any relevant laboratory results. The RN com-pletes an initial nursing plan of care based on a comprehensive nursing assessment (includ-ing the determinants of health that influence client health outcomes) and establishes the complexity of client condition.

Pre-admission

Padmission occurs prior to the client re-ceiving surgery, sedation/analgesia and anes-thetic agents/techniques. Pre-operative as-sessments are to be completed and the plan of care is initiated.

Day of Surgery

The day of surgery admission occurs prior to the client receiving surgery, sedation/anal-gesia and anesthetic agents/techniques. The nurse (RN/LPN) in this phase focuses on vali-dating the established plan of care to contin-ue to prepare the client for surgery.

Non-elective Admissions

For admissions that are urgent (surgery re-quired in 72 hrs.), the admission information may be gathered by the RN, or the LPN in col-laboration with the RN. The RN must develop the plan of care, having reviewed the data gathered before the client is admitted to the operative area.

The preoperative phase includes:

Pre-admission

Day of surgery

Non-elective Admissions

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Collaborative Care Guidelines • Phases of the Perioperative Experience • The Preoperative Phase

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Considerations

1 The data collected in the pre-operative phase is used to develop the plan of care for

surgical clients and must be initiated or reviewed by an RN prior to admission to the intra operative phase.

2 The information obtained during this phase may span a lengthy period of time (one week

up to one year); therefore it is important to review all the data that has been gathered prior to the day of surgery admission and to confirm there are no health history changes. If changes are noted, all information should be verified and reviewed by an RN or RN/ LPN collaboration.

3 The RN will determine what category of nurse cares for the client (client assignment)

which is dependent on clients care needs. Factors to consider are the client acuity (ASA classification) [Appendix A], the scope of practice of the nurse, the nurses’ own individual competence, the scope of employment and the practice environment (e.g. number of nursing resources, allied health team members and policies available).

4 Admission on the day of surgery (Day Surgery), if the data collected prior to this visit has

been reviewed in its entirety by an RN then the admission can be initiated by either an LPN or an RN. If the information has not been reviewed, then an RN must be involved in this admission, either by completing the admission assessment themselves or validating the admission assessment completed by the LPN.

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The Intraoperative Phase

The intraoperative phase includes:

Immediate preoperative

Intraoperative

Immediate postoperative

Intraoperative

Intraoperative consists of the period when the client is transferred to the operating ta-ble to when the client is admitted to the post anesthesia area. There are two primary roles for nurses within the operating theaters, the scrub role and the circulating role. The circu-lating role can be subcategorized as a prima-ry circulator, and secondaprima-ry circulator. (RN/ LPN circulating role psychomotor skills can be found in Appendix B. RN/LPN scrub role psy-chomotor skills can be found in Appendix C).

Scrub Role

The role of the scrub nurse is to assist the scrubbed personnel in the operating theater. Responsibilities include but are not limited to; setting up the surgical field, maintaining sterility of the surgical field, prepping, drap-ing, and surgical counts. This surgical team member remains in the sterile field for the duration of the procedure, anticipating and providing the required instruments, supplies, and equipment to perform the surgery. Both RN`s and LPN`s who possess the knowledge and the competency to do so, may assume this role.

The intraoperative phase of care occurs in a team directed environment. Practitioners work collaboratively to ensure a safe surgical experience for clients. The settings and the availability of resources may vary, depending on the facility.

Immediate preoperative

Immediate preoperative consists of the peri-od where the OR nurse receives the client to the placement of the client on the OR table. During this period the RN/LPN and the surgi-cal team validate and contribute to the estab-lished plan of care. The RN/LPN is responsible to implement and evolve the plan of care that has been initiated in the preoperative phase. In order to ensure optimal client outcomes, communication between team members is essential so that all are aware of the individu-alized plan of care for each client.

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Collaborative Care Guidelines • Phases of the Perioperative Experience • The Intraoperative Phase

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Primary Circulating Role

The role of primary circulator is to provide leadership and coordinate the individual care and needs of the client and surgical team by: disseminating information, planning, organiz-ing, delegatorganiz-ing, implementorganiz-ing, coordinating and evaluating perioperative activities (OR-NAC, 2011)

This role is filled in nursing by the RN. In this role the RN completes and interprets an in-depth situational assessment and is respon-sible for coordinating activities within an op-erating room, directs the work of unlicensed personnel and the nursing team in a collab-orative manner within each theater, and responds independently or in collaboration with other healthcare providers to unstable, unpredictable and emergency situations. The development of a plan of care (if not already developed or if no standard plan) is the re-sponsibility of the primary circulator.

Secondary Circulating Role

The secondary circulating role within the Perioperative Services program may be filled with a Perioperative RN or LPN. It is a col-laborative role which makes adjustments to existing nursing care plans, as long as the cli-ent is achieving the outcomes anticipated. In this role, the nurse performs ongoing assess-ments of the client and their response to in-terventions and compares their assessment findings to expected findings. When client outcomes are not as anticipated, changed or new, or if the client is not achieving intend-ed outcomes or client status is becoming less predictable the second circulator consults the appropriate care provider.

Immediate postoperative

Immediate postoperative is the period in which there is emergence and transfer of cli-ent care to the appropriate health care pro-vider (ORNAC, 2011).

Considerations

1 The LPN uses the established plan of care to guide their decisions and practice. The

LPN is expected to perform ongoing assessments of the client and their response to the interventions and compare their assessment findings to expected findings. They independently make the appropriate adjustments to the nursing care plan as long as the client is achieving the outcomes as anticipated. LPNs must consult the appropriate care provider when assessment findings:

• are not as anticipated, changed or new • client is not achieving intended outcomes • status is becoming variable or less predictable

2 When preoperative procedural rooms require a sterile set up only, with no further scrub

responsibilities, such as some ENT, Urology and Gynecology procedures then staffing may be two nurses only, one of which must be an RN. Measures must be in place to ensure extra resources are available and will respond in an emergency situation e.g. emergency buzzers systems alerting any available staff in adjacent area to respond, code response teams, and or rapid response teams. Procedural rooms are most often staffed during day shifts when extra resources are available.

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3 The RN or LPN are responsible to implement and evolve the plan of care that has been

initiated or developed by a preoperative RN. In order to ensure positive client outcomes, communication between team members is essential so that all are aware of the

individualized plan of care of each client.

4 The intraoperative assessment may need to be completed by the primary circulator if:

• the complexity of the client condition is above ASA 1 or 2;

• the client has not been previously assessed by an RN in the preoperative phase and, • clients undergoing procedures that do not have an established plan of care.

5 The LPN may assume the role of secondary circulator as long as:

a) There is an agency policy in place to support this practice.

b) The scrub role is being filled by a RN. (The intent of this recommendation is to support the practice of a having an RN in the room at all times. This recommendation does not imply that RNs, who are in the scrub role, will be expected to break the scrub role to deal with an unanticipated event.)

c) She /he have the knowledge, skill and judgment to perform the role;

d) There is immediate access to and a rapid communication plan for the LPN to connect with the RN (or other appropriate care provider) if there are unanticipated changes in the clinical situation.

6 The current clinical situation supports the LPN to assume this role when the primary

circulating nurse is absent from the OR theatre, as evidenced by:

a) The primary circulating RN has completed and interpreted an in-depth situational assessment, noting that the clinical situation is well understood, readily managed and has low risk for unanticipated events;

b) The primary circulating RN and LPN have exchanged appropriate clinical information and both agree to the findings of the situation assessment.

7 In the absence of an anesthesiologist or anesthesiologist assistant, the RN can administer

or assist other team members in the administration of sedation/analgesia and/or anesthetic agents/techniques to the client and monitor the client for immediate or delayed responses to such pharmalogical agents by objective assessment, data collection and constant monitoring. If the anesthesia phase of sedation/analgesia occurs in the OR environment, the primary role of the RN administering the sedation/analgesia is to provide constant monitoring of the client’s needs and to provide immediate interventions when the client’s health status changes.

8 If there are only two nurses assigned to a room, and one is an LPN, the scrub role will be

filled by the LPN and the circulating role will be assigned to the RN. This may occur when the determination of patient care needs and environmental conditions identify that only two nurses will be caring for the intraoperative patient, with no additional RN supports available or when on call schedules identify that only two nurses are scheduled

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Collaborative Care Guidelines • Phases of the Perioperative Experience • The Intraoperative Phase

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Intraoperative Decision Making Algorithm

The algorithm, on the following page, is intended to support RNs effective decision making that matches intraoperative client needs with either a RN or a LPN. For each decision one must con-sider the following equally important factors: the client acuity, the scope of practice of the nurs-ing role, the nurses’ own individual competence, the scope of employment and the practice environment (e.g. number of nursing resources, allied health team members and organizational policies).

Intraoperative decision making algorithm (adapted from the IWK Adult Surgical Perioperative Collaborative Care Guidelines, 2010)

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The LPN may assume the role of secondary circulator

when the primary circulating nurse is absent from the OR theater, as evidenced by;

1 The primary circulating RN has completed and interpreted an in-depth situational assessment, noting that the clinical situation is well understood, readily managed and has low risk for unanticipated events;

2 The primary circulating RN and LPN have exchanged appropriate clinical information and both agree to the findings of the situation assessment;

Intraoperative Nursing Assignment (RN)

Decision Making Framework

for the role of the Perioperative Licensed Practice Nurse (LPN)

Predictable Plan of Care

Client Condition: Client is ASA 1 or 2 (see Appendix A)

and the surgical procedure is familiar (very well established plan of care and expectation of care delivery and roles/responsibilities for nursing).

Environment Factors:

• Surgical unit performs any given procedure frequently (has a well-established plan of care for procedures done frequently).

• Predictable client outcomes.

• Availability of RN with assignment to primary circulator (establishment of nursing surgical plan of care).

The focus of the secondary circulator role is to assist

the scrub RN to set up, count and circulate with the primary circulating RN during the case.

Role of LPN

• reviews the pre-operative checklist, completes nursing assessment (compare findings with the expected) and collaborates with the appropriate healthcare provider.

• performs surgical safety checklist and admits client to the OR, collaborates with RN regarding plan of care.

• may assist during induction and intubation of stable, predictable clients under the direction of an anaesthesiologist, and in the presence of a RN.

The LPN may assume the role of secondary circulator as long as:

1 There is an agency policy in place to support this practice;

2 The scrub role is being filled by a RN;

3 She /he have the knowledge, skill and judgment to perform the role;

4 There is immediate access to and a rapid communication plan for the LPN to connect with the RN (or other appropriate care provider) if there are unanticipated changes in the clinical situation.

NOTE: The RN is required to assist

with awake intubation, facial/neck trauma and/or deformities, difficult intubation, because these situations are always considered complex and unpredictable regardless of patient acuity.

Three nurses assigned to room.

2 RN and 1 LPN

Perioperative Licensed Practical Nurse (LPN) acts in the scrub role OR second circulator role in the presence of a circulating RN.

Unpredictable Plan of Care

Client Condition: Client’s condition is such as

• Unstable ICU clients • Trauma clients

• Level 1 (life threatening emergency) clients • Complex client–+ co-morbidities; ASA 3, 4 or 5

(see Appendix A)

Environment Factors:

• Surgical unit performs any given procedure infrequently (would not have a well-established plan of care for procedures done infrequently. • Surgery that is not typically performed. • Difficult to predict client outcomes.

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Collaborative Care Guidelines • Phases of the Perioperative Experience • The Postoperative Phase

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The Postoperative Phase

The postoperative phase is divided into Post Anesthesia Phase I, Post Anesthesia Phase II, and Extended Observation Phase. (National

Association of Perianesthesia Nurses of Can-ada: Standards of Practice, 2011)

Post Anesthesia Phase I

This phase occurs directly after the surgery and the administration of sedation/analgesia and/or anesthetic agents/techniques. The perianesthesia clients’ needs are of highest priority and constant monitoring of these life - sustaining needs is neither minimal nor epi-sodic (NAPAN©, 2011). Therefore, the RN is the most appropriate nursing care provider at this phase. When the client obtains op-timal health in this phase, the client can be transitioned to post anesthesia phase II. Discharge Scoring Systems which have evi-denced–based discharge criteria are utilized to allow the Perianesthesia RN to determine individual client readiness for transfer be-tween Post Anesthesia Phases. These dis-charge criteria are utilized in accordance with the health care institution’s polices and

crite-ria endorsed by Departments of Anesthesia. i.e. Aldrete Scoring System & Post Anesthetic Scoring System (PADDS) (NAPAN©, 2011) Levels of sedation include: minimal, moder-ate, deep, and general anesthesia. (National

Association of Perianesthesia Nurses of Cana-da: Standards of Practice, 2011). The table

Ef-fects of Types of Sedation and General Anes-thesia (Odom –Forren & J, Watson, D., 2005) is included in Appendix D.

Post Anesthesia Phase II

Phase II occurs directly after Phase I. The perianesthesia client’s potential requirement for life-sustaining interventions is monitored and immediate interventions are provided when the client’s immediate physical/com-fort needs are not being met. The client par-ticipates in providing the nurse data related to the current state of health. The RN is the most appropriate nursing care provider at this phase. When the client obtains optimal health in this phase, the client can be tran-sitioned to the extended observation phase.

The Postoperative phase includes:

Post Anesthesia Phase I

Post Anesthesia Phase II

Extended Observation Phase

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Considerations

1 Post Anesthesia Phase I- the care required is of a high acuity, with constant monitoring

required of life sustaining client needs which may require independent, immediate interventions to manage a client with changing health status. In these situations, as well as situations where the client cannot maintain their own airway without intervention (such as deep or general anesthesia) the RN is the appropriate nursing care provider. NAPAN© supports the position that this first phase of nursing care is a critical care unit .Clients may be unconscious, unstable and critically ill with complex physiologic or/pyschologic requirements. Overall general competencies are those of a critical care nurse (Appendix E). (NAPAN©,2011)

2 Post Anesthesia Phase II- the care is acute. Potential client need for life sustaining

measures is monitored and immediate interventions are provided when the client’s immediate physical/comfort needs are not being met. The RN is the appropriate nursing care provider. Critical Care competencies are required in this area.

3 Extended Observation Phase- the care is ongoing while monitoring the client’s progress

towards recovery and ultimately discharge, thus is within scope of both nursing roles, providing the LPN works in collaboration with the RN. In this phase where the client has received moderate sedation, the LPN, in collaboration with the RN, may care for clients who have and can maintain their airways with no interventions.

4 If an LPN is caring for a client and the predictability of the condition changes then the

LPN must collaborate with the appropriate care provider. Where possible, the LPNs first collaborator is the RN.

Extended Observation Phase

The extended observation phase occurs di-rectly after post anesthesia phase II. The role of the nurse in the observation phase is to monitor the client’s progress towards recov-ery and ultimately discharge. The perianes-thesia nursing interventions are focused on

preparing the client for self-care in the home, an inpatient setting, nursing homes, rehab centers etc. In this phase an RN & LPN are appropriate care providers working collabo-ratively to their individual scopes of practice.

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Collaborative Care Guidelines • Definitions / Glossary

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Definitions / Glossary

Accountability: a moral concept; it infers

ac-ceptance of consequences for decisions and/ or actions, and is a liability (legal responsi-bility) for task performance. Accountability cannot be delegated. RNs and LPNs are ac-countable to practice in a manner consistent with their professional responsibilities, their respective Code of Ethics and legal guide-lines, and their standards of practice (College

of Licensed Practical Nurses of Nova Scotia (CLPNNS), 2002).

Acuity: the degree of severity of a client’s

condition and /or situation.

ASA (American Society of Anaesthesiolo-gist) Classification: a system used by

anaes-thesiologists to stratify severity of clients’ underlying disease and potential for suffer-ing complications from general anaesthesia (McGraw-Hill Concise Dictionary of Modern

Com-panies, Inc.)

Assessment by Nurses: the gathering of

in-formation about a client’s physiological, psy-chological, sociological, and spiritual status. Assessment is the first stage in the nursing process in which the nurse carries out a completed and holistic nursing assessment. The nursing process includes assessment, planning, implementation and evaluation (CRNNS, 2012).

Collaboration: working together as a

health-care team by respecting and acknowledging the roles of all those within the healthcare system in contributing to safe, compassion-ate, competent and ethical care. (Adapted from RN Act, 2006).

Collaborative Practice: a process of active participation, communication and deci-sion-making of two or more healthcare pro-viders, in partnership with a person receiving care. The health care providers use their sep-arate and shared knowledge and skills during the planning, implementation and evaluation phases of person-centered care.

Interpro-fessional collaborative practice is centered on the needs of clients; enabling them to be partners in their care, with the most ap-propriate health professionals providing the services required to meet their healthcare needs” (Health Professions Regulatory Net-work, 2008).

Competence: the ability to integrate and

apply the knowledge, skills and judgment required to practice safely and ethically in a designated role and practice setting and in-cludes both entry-level and continuing com-petencies (RN Act, 2006).

Competency: the integrated knowledge,

skills, judgment and attributes required of a nurse to practice safely and ethically in a des-ignated role and setting (Attributes include, but are not limited to, attitudes, value and beliefs.) (CNA, 2008).

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20

Operating Room: a room in a health care

facility in which surgical procedures are per-formed which may or may not require anes-thesia.

Optimal Postoperative Condition: is the

most desirable or satisfactory condition fac-toring in the anticipated and unanticipated effects of all preceding surgical or anesthetic interventions (National Association of

Peri-anesthesia Nurses of Canada (NAPAC) Stan-dards of Practice, 2011).

Primary Circulating Role: the role of primary

circulator is to provide leadership and coor-dinate the individual care and needs of the client and surgical team by: disseminating information, planning, organizing, delegat-ing, implementdelegat-ing, coordinating and evalu-ating perioperative activities (ORNAC, 2011). This role is filled in nursing by the RN. This role completes and interprets an in-depth situational assessment and is responsible for coordinating activities within an operating room, directs the work of unlicensed person-nel and the nursing team in a collaborative manner within each theater, and responds independently or in collaboration with other healthcare providers to unstable, unpredict-able and emergency situations.

This role plans, collaborates, coordinates, implements and evaluates the functioning of the room and makes adjustments as required based on clients’ need. The development of a plan of care (if not already developed or if no standard plan) is the responsibility of the primary circulator.

Secondary Circulating Role: the

second-ary circulating role within the Perioperative Services program may be filled by a Periop-erative RN or LPN. It is a collaborative role which makes adjustments to existing nursing care plans, as long as the client is achieving the outcomes anticipated. This role plans, collaborates, implements and evaluates the functioning of the room and makes adjust-ments as required based on clients’ need. The secondary circulating nurse position performs ongoing assessments of the client and their response to interventions and com-pares their assessment findings to expected findings. When client outcomes are not as anticipated, changed or new, the client is not achieving intended outcomes or client status is becoming less predictable the second circu-lator consults the appropriate care provider. The LPN may assume the role of secondary circulator as long as:

a) There is an agency policy in place to support this practice.

b) The scrub role is being filled by a RN. (The intent of this recommendation is to support the practice of a having an RN in the room at all times. This recommendation does not imply that RNs, who are in the scrub role, will be expected to break the scrub role to deal with an unanticipated event.)

c) She /he have the knowledge, skill and judgment to perform the role; d) There is immediate access to and a

rapid communication plan for the LPN to connect with the RN (or other appropriate care provider) if there are unanticipated changes in the clinical situation.

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Collaborative Care Guidelines • Definitions / Glossary

21

The current clinical situation supports the LPN to assume this role when the primary cir-culating nurse is absent from the OR theatre, as evidenced by:

a) The primary circulating RN has

completed and interpreted an in-depth situational assessment, noting that the clinical situation is well understood, readily managed and has low risk for unanticipated events;

b) The primary circulating RN and LPN have exchanged appropriate clinical information and both agree to the findings of the situation assessment

Nursing Plan of Care: the nursing plan of

care is an outline of the nursing interventions that are to be provided to an individual and/ or family. It is a set of actions the team will implement to resolve/support nursing diag-noses identified by nursing assessment. It guides in the ongoing provision of nursing care and assists in the evaluation of that care.

Surgical Plan of Care: for each client coming

to the OR, there is an established plan of care in place, based on surgical procedures. The role of the assessment and plan of care evo-lution is for the perioperative nurse to assess the client in the context of the surgical plan of care and adjust the nursing Plan of Care (POC) accordingly. For each surgical proce-dure there are standard nursing assessment areas (ORNAC standards pages 163,164, 286-294) in addition to surgery specific areas to be assessed to ensure safe, quality, client care outcomes.

Practice of Nursing: the application of

spe-cialized and evidence based knowledge of nursing theory, health and human sciences, inclusive of principles of primary health care, in the provision of professional services to a broad array of clients ranging from stable or predictable to unstable or unpredictable, and includes:

i. assessing the client to establish their state of health and wellness;

ii. identifying the nursing diagnosis based on the client assessment and analysis of all relevant data/information;

iii. developing and implementing the nursing component of the client’s plan of care;

iv. coordinating client care in collaboration with other health care disciplines; v. monitoring and adjusting the plan of

care based on client responses; vi. evaluating the client’s outcomes; vii. such other roles, functions and

accountabilities within the scope of practice of the profession, which support client safety and quality care, in order to:

A. promote, maintain or restore health; B. prevent illness and disease;

C. manage acute illness; D. manage chronic disease; E. provide palliative care; F. provide rehabilitative care;

G. provide guidance and counseling; and

H. make referrals to other health care providers and community resources, also includes research, education, consultation, management, admin-istration, regulation, and policy or system development relevant to the above. (RN Act 2006)

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22

Practice of Practical Nursing: the provision

of nursing services independently, for cli-ents considered stable with predictable out-comes, and under the guidance or direction of a registered nurse, medical practitioner or other health care professional authorized to provide such consultation, guidance or direc-tion, for clients considered unstable with un-predictable outcomes (LPN Act, 2006).

Predictable: the extent to which one can

identify in advance a client’s response on the basis of observation, experience or scientific reason (LPN Act, 2006, RN Act, 2006).

Scope of Employment: a range of

responsi-bilities defined by an employer through job / position descriptions and policies.

Scope of Practice: encompasses the roles,

functions, and accountabilities which regis-tered nurses and licensed practical nurses are educated and authorized to perform (RN Act, 2006 LPN Act, 2006).

Stable in the Operating Room setting: the

clients’ health status can be anticipated (ASA Physical classification 1 or 2), the plan of care is readily established, and is managed with interventions that have predictable out-comes. The surgery planned is routinely done in the particular perioperative setting, with an established plan of care. (The RN Exam

Competency Project, CNA, 2003; CLPNNS Standards of Practice, 2011; Capital Health Interdisciplinary Clinical Manual)

Standard: an authoritative statement that

sets out the legal and professional basis for one’s professional practice. The primary rea-son for having standards is to promote, guide, direct and regulate practice within ones pro-fession. (CRNNS, 2012)

Surgical Suite: the floor or area where the

operating rooms are located, including the OR lounges and change rooms.

Unstable in the Operating Room Setting: a

situation in which a client’s health status is fluctuating, with atypical responses (ASA classification 3, 4, 5). An unstable case is com-plex, requiring frequent assessment of the client and modification of the care plan, and may include interventions that may have un-predictable outcomes and/or risks. Examples of Unstable/Unpredictable perioperative cli-ents would be Level 1(life threatening emer-gency cases), unstable ICU clients and trauma clients as well as surgeries that are complex/ infrequently done in the perioperative area, and do not have an established plan of care.

Unpredictable: that a client’s health

out-come cannot reasonably be expected to fol-low an anticipated path (LPN Act, 2006, RN Act, 2006).

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Collaborative Care Guidelines • References

23

References

Capital Health District: Halifax, Nova Scotia (2008). Interdisciplinary clinical manual: Policy number CC02-008.

Canadian Nurses Association. (2008). Code of ethics for registered nurses. Ottawa, Ontario: Author.

Canadian Nurses Association. (2003, July).RN exam competency project. Ottawa, Ontario: Author.

College of Licensed Practical Nurses of Nova Scotia. (2005). Entry level competencies for licensed practical Nurses. Halifax, Nova Scotia: Author.

College of Licensed Practical Nurses of Nova Scotia. (2011). Scope of Practice, Standards of Practice, Code of Ethics for LPNs. Halifax, Nova Scotia: Author.

College of Licensed Practical Nurses of Nova Scotia (2002). Position statement: Use of protected title Licensed Practical Nurse in Nova Scotia. Halifax, Nova Scotia: Author.

College of Licensed Practical Nurses of Nova Scotia (2012). Scope of Practice: Section Z: Perioperative Specialty of Competency Profile. Halifax, Nova Scotia: Author.

College of Registered Nurses of Nova Scotia (2009). Entry-level competencies for registered nurses in Nova Scotia. Halifax, Nova Scotia: Author.

College of Registered Nurses of Nova Scotia (2011). Standards of practice for registered nurses. Halifax, Nova Scotia: Author.

Canadian Council for Practical Nurse Regulators (CCPNR)/ Counsel Canadian de Reglementation des soins infirmiers auxiliaries (CCRSIA) (2010). Standards of Practice and Competencies for Perioperative Licensed/Registered Practical Nurses.

College of Registered Nurses of Nova Scotia and College of Licensed Practical Nurses of Nova Scotia (2012).Effective Utilization of RNs and LPNs in a Collaborative Practice Environment. Halifax, Nova Scotia: Author.

College of Registered Nurses of Nova Scotia (2009). Scope of Nursing Practice for Registered Nurses in Nova Scotia. Halifax, Nova Scotia: Author.

College of Registered Nurses of British Columbia and College of Licensed Practical Nurses of British Columbia (December 2006). Operating Room LPNs in BC: Utilization, Role, Scope, Competencies and Qualifications.

Capital Health District: Halifax, Nova Scotia (2010). LPN Circulating Role Competencies. Drain, C.B. & Odam-Forrren, J. (2009) Perianesthesia Nursing a Critical Care Approach (5th

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Goodman, B. MHS, RN, CPAN, CAPA (2009). ASPAN Competency Based Orientation & Credentialing for RN’s in Perianesthesia Settings.

Health Professions Regulatory Network. (2008). Position Statement on interprofessional collaborative practice. Halifax, NS: Author.

Interior Health Surgical Services (October 2011).Operating Room Licensed Practical Nurse (LPN)- Competencies.

Izaak Walton Killam Health Center (2010). Adult Surgical Perioperative Licensed Practical Nurse (LPN): Collaborative Care Guidelines. Halifax, Nova Scotia.

LeClerc, C. M., Doyon, J., Gravelle, D., Hall, B., & Roussel, J. (2008). The autonomous-collaborative care model: Meeting the future head on. Nursing Research, 21(2), 63-75. Licensed Practical Nurses Act, c.17. (2006) Statues of Nova Scotia. Halifax, NS: Government of

Nova Scotia.

McGraw-Hill Company (2002). Concise Dictionary of Modern Medicine. Columbus, OH: The McGraw-Hill Companies, Inc.

National Association of PeriAnesthesia Nurses of Canada. (2011). Standards of Practice, 2nd Edition. Oakville, Ontario: Author

Odom-Forren, J & Watson, D. (2005). Practical guide to moderate sedation/analgesia, 2nd Ed. Washington: Elsevier Mosby in National Association of PeriAnesthesia Nurses of Canada: Standards of Practice (2011), p.230.

Operating Room Nurses Association of Canada (2011). Standards, Guidelines and Position Statements for Perioperative Registered Nursing Practice.

Registered Nurses Act, c.21. (2006) Statues of Nova Scotia. Halifax, NS: Government of Nova Scotia.

Schreb, C. (2001). Describing nursing effectiveness through standardized nursing languages and computerized clinical data. Digital Dissertatives (AAT 3034148).

The Cleveland Clinic Foundation. (2009). Retrieved from http://my.clevelandclinic.org/services/ anesthesia/hic_asa_physical_classification_system.aspx

White, P. & Pringle, D. (2005). Collecting patient outcomes for real: The nursing and health outcomes project. Nursing Leadership, 18(1), 26-33.

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Collaborative Care Guidelines • Appendix B • Circulating Role Psychomotor Skills

25

Circulating Role

Psychomotor Skills

APPENDIX

A

According to the Guidelines: Effective Utilization of RNs and LPNs in a Collaborative Practice

Envi-ronment (2012), Registered Nurses, Licensed Practical Nurses and managers must be aware that

effective decisions to match client needs with either a registered nurse or a licensed practical nurse, should be based on the following equally important factors: the client acuity, the scope of practice of the nursing role, the nurses’ own individual competence, the scope of employment and the prac-tice environment (e.g. number of nursing resources and allied health team members).

Professional Conduct RN LPN

Identifies learning needs and seeks opportunities for improvement. X X

Accountable for actions and decisions at all times. X X

Practices according to applicable Standards for Nursing Practice,

Code of Ethics and Perioperative standards. X X

Maintains knowledge of current DHA/IWKs policies and procedures. X X

Practices according to CRNNS Standards. X

-Practices according to CLPNNS Standards. - X

Accepts and gives feedback in a positive and respectful manner. X X

Act as a role model. X X

Arrives on time to assigned OR suite and appears mentally prepared for shift. X X

Takes breaks appropriately and within the scheduled times. X X

Completes applicable forms for any adverse event. X X

Aware of methods of communication

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Room Set Up RN LPN

Adheres to Operating Room Dress Code. X X

Collaborates with nurses in the room to determine scrub and circulating

opportunities. X X

Documents applicable times and any delay codes X X

Ensures that suction, lights, electrosurgical units are functioning and

communicates any concerns to team members. X X

Remove and report any malfunctioning equipment X X

Ensures any required furniture and equipment are available as well as IV

solutions and anesthesia equipment. X X

Checks case carts and ensures appropriate instrumentation and supplies are

available. X X

Notifies other disciplines if and when they are required

(i.e. radiology, pathology, etc.). X X

Ensures availability of implants or special equipment if possible in collaboration

with the surgeon(s). X X

Participates in Phase 1 “Check In” of the Surgical Safety Checklist X X

Creating a Sterile Field RN LPN

Checks table surfaces for wetness or dust before placing sterile bundles on them. X X Ensures integrity of sterile containers/packages and sterilization indicators prior

to and after opening them. X X

Opens all types of sterile supplies (containers, peel pouches, bundles) according

to principles of asepsis. X X

Does not leave opened sterile supplies unattended. X X

Takes corrective action when breaks in aseptic technique occur. X X

Opens and adds solutions and medications to the sterile field X X

Remains at least one foot from the sterile field. X X

Fiscally and environmentally responsible - Only opens items known to be used consistently (determined through collaboration between scrub and circulating nurses).

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Focused Assessment RN LPN

Introduces self to client in pre-op area or outside OR suite for focused

assessment. X X

Determines client’s level of consciousness/ability to effectively communicate. X X

Review and implement plan of care X X

Refer to plan of care and compare actual findings to expected findings X X

Develop plan of care based on assessment findings and proposed surgery X -Consult appropriate care provider when assessment findings:

1) Are not anticipated, changed or new 2) Client is not achieving intended outcomes 3) Status is becoming variable or less predictable

X X

Provides emotional support and information to the client and family.

Determines clients coping mechanisms including support systems. X X

Verifies pre-operative checklist is complete with the following (but is not limited to): valid consent, history and physical, test results, requirements and availability for blood products, NPO status, etc.

X X

Retrieve/view test results, x-rays, old charts, etc. X X

With the client confirm identity, procedure, operative site marked (if applicable), allergies, presence of prosthesis/implants, jewellery, dentures, cultural concerns and any other pertinent information.

X X

Communicates with nurses in the room pertinent information collected during the focused assessment (i.e. allergies, operative site, psychological state/anxiety level, mobility, etc.).

X X

Collaborates with the client and interprofessional team to develop healthcare

goals and outcomes. X X

Document relevant assessment information in client chart. X X

Participates in Phase 2 “ Time Out” of the Surgical Safety Checklist,

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Surgical Count RN LPN

Performs count according to DHA/IWK Operating Room Count and

Incorrect Count policies. X X

Performs extent of surgical counts in accordance with DHA/IWK policy X X

Performs surgical counts X X

When a sponge or suture package contains an incorrect number, circulator bags

and removes from OR suite. X X

Counts off, bags and retains sponges in units as issued (i.e. 5 or 10). X X Circulating nurse directs the flow of closing count(s) following the order of items

on count record. X X

Legibly records all counted items. X X

Completes applicable forms for any adverse event, if applicable X X

Assisting Anesthesia RN LPN

Assist anesthesiologists with:

Clients have an awake intubations X

-Clients with difficult airways X

-Clients with facial/neck trauma; deformities X

-Stable /predictable clients - undergoing:

• General anesthetic X X • Local anesthetic X X • Conscious sedation X X • Spinal X X • Epidural X X • Blocks X X Unstable/unpredictable clients X

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-Collaborative Care Guidelines • Appendix B • Circulating Role Psychomotor Skills

29

Document Anesthesia in and start times X X

Ensures clean IV, endotracheal tube (ET), 20cc syringe, functioning laryngoscope

and other equipment/lines as required. X X

Safe transfer of client to OR table or make comfortable on stretcher/bed. Untie

gown, ensure client is not lying on gown/blankets, provide warm blankets, etc. X X Apply the safety strap and/or remains at the bedside until client fully

anaesthetized. X X

Stays with client and provides emotional support. X X

Apply monitoring equipment. X X

Communicates all actions to the client at all times. X X

Assists anesthesia with IV initiation (passes tape, starts flow, etc.). X X

Provides a quiet environment during intubation. X X

Assist with head tilt/burp/cricoid pressure as requested by anesthesia. X X Passes ET tube/LMA to anesthetist and firmly holds in place until secured. Under

direction of anesthetist instills air into ET tube. X X

If tube placement is not correct, prepares for re-intubation or assists with

ventilation as directed by anesthesia. X X

Inserts urinary catheter as required and documents same. X X

Documents type of anesthetic used. X X

Notes physiological status and reports changes to anesthetist. X X

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Supine RN LPN

Identifies appropriate table and/or table attachments and ensures are available. X X

Demonstrates ability to apply table attachments. X X

Ensures safe transfer of client (i.e. locking table and stretcher/bed, use of

transfer device, appropriate number of staff, etc.). X X

Apply the safety strap and/or remains at the bedside until client fully

anaesthetized. X X

Safely positions arms at client’s sides or on padded arm boards. X X

Familiar with controls (i.e. raise/lower bed, trendelenburg, tilting right/left, etc.). X X Recognizes and implements action to address problem areas such as bony

prominences (i.e. elbows, heels, coccyx, hips, etc.). X X

Checks that arms and legs are not over extended >900, unless required

and pads and secures them. X X

Ensures height of arm is the same as bed mattress X X

Completes head to toe check ensuring appropriate positioning measures

fully achieved. X X

Maintains client warmth and dignity. X X

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Prone RN LPN

Identifies appropriate table and/or table attachments and/or frames

and ensures are available. X X

Apply the safety strap and/or remains at the bedside/stretcher until client fully

anaesthetized. X X

Familiar with controls (i.e. raise/lower bed, trendelenburg, tilting right/left, etc.). X X Collaborate with anesthesia regarding airway, venous/arterial access and

physiological changes due to position. X X

transfer device, appropriate number of staff, devices in place, etc.). X X

Ensures arms are safely secured at the client’s sides or rolled in a natural arc and

placed on padded arm boards at the side of the head. X X

Recognizes and implements action to address problem areas such as bony prominences (i.e. elbows, toes, hips, etc.), breasts, genitalia, external lines/bags/ tubes.

X X

Checks that arms and legs are not over extended, unless required and pads and

secures them. X X

Completes head to toe check ensuring appropriate positioning measures fully

achieved. X X

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Lithotomy RN LPN

anaesthetized. X X

Familiar with controls (i.e. raise/lower bed and foot of bed, trendelenburg,

tilting right/left, etc.). X X

Ensures legs are raised and positioned simultaneously. At end of case lowers

legs simultaneously. X X

Collaborate with anesthesia regarding airway, venous/arterial access and

Recognizes and implements action to address problem areas such as bony

Checks that arms and legs are not over extended, unless required and pads and

secures them. X X

achieved. X X

Communicates and appropriately documents client positioning. X X

When raising foot of bed at the end of the case ensures fingers are protected

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Lateral RN LPN

Identifies appropriate table and/or table attachments and/or frames and ensures

are available. X X

transfer device, appropriate number of staff, devices in place, etc.). X X

Apply the safety strap and/or remains at the bedside/stretcher until client fully

anaesthetized. X X

Collaborate with anesthesia regarding airway, venous/arterial access and

Familiar with controls (i.e. raise/lower bed, trendelenburg, tilting right/left, etc.). X X

Ensures arms are safely positioned and padded. X X

prominences (i.e. elbows, knees, ankles, hips, etc.) and genitalia. X X

achieved. X X

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Park Bench RN LPN

anaesthetized. X X

Familiar with controls (i.e. raise/lower bed, trendelenburg, tilting right/left, etc.). X X Collaborate with anesthesia regarding airway, venous/arterial access and

achieved. X X

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Skin Preparation (Prep) RN LPN

Confirms correct surgical site with consent and site marking prior to prepping. X X Selects appropriate skin prep solution while considering client allergies and

solution action/mechanism. X X

Consults the surgeon’s pick sheet for skin prep preferences. X X

Documents client skin condition prior to prepping and/or hair removal. X X

Confirms with anesthesia that prepping may proceed. X X

If client awake, informs the client of steps involved. X X

Places drip sheets under prep area to absorb excess prep solution. X X

If holding the limb, ensure safe movement of client limb. X X

Removes drip sheets once prep complete without

contaminating the prepped area. X X

If required, performs hair removal using electric clippers. X X

Follows principles of asepsis during skin prep (as per ORNAC standards). X X Documents skin prep solution, who prepped and skin condition post-procedure. X X

Pneumatic Tourniquet RN LPN

Ensures unit is functioning prior to case. X X

Collects supplies – correct cuff size (sterile/unsterile), webril and/or eschmark. X X

Confirm with the surgeon pressure setting required for the case. X X

Ensures prep solution is not pooled around cuff. X X

Announces tourniquet time audibly to the surgeon at the following intervals: one

hour, 1.5 hours, and 2 hours (very rare). X X

Document tourniquet site(s), pressure settings, time of inflation/deflation, BME number, and notification to surgeon of elapsed time and skin condition following cuff removal.

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Electrocautery (ESU) RN LPN

Ensures unit is functioning prior to case. X X

Collects supplies – foot pedals, grounding pads, adaptors, smoke evacuator

filters/tubing, accessories, etc. X X

Confirm settings with the surgeon prior to case. X X

Aware of client safety concerns related to this equipment. X X

If Megapad is not being used, applies grounding pad after client is positioned and prior to prepping and draping. Ensures grounding pad is well adhered to skin surface.

X X

Applies grounding pad to well-muscled area as close to operative site as possible. Avoids bony prominences, skin folds, scar tissue, prostheses, skin rashes and areas of impaired circulation.

X X

Places foot pedal for use in endoscopic, or with bipolar cautery. X X

Documents skin condition prior to placement of grounding pad. X X

Document skin condition after removal of grounding pad. X X

Documents BME # and setting on client health care record. X X

If Megapad is being used, ensure proper positioning (not under VAC pack,

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Circulating Role (During Procedure) RN LPN

Immediately prior to incision, participates in phase 2 “Time Out” of the Surgical;

Safety checklist X X

Documents Procedure Start time X X

Effectively communicates and collaborates with interdisciplinary team

throughout the case. X X

Notes/monitors physiological status and reports changes to anesthetist. X X Ability to prioritize multiple requests from members of the interdisciplinary

team. X X

Ability to anticipate the needs of the surgical team. X X

Responds to and prioritizes requests/needs of the surgical team. X X

Takes action to prevent and/or respond to potential or adverse event or

emergency situation. Recognizes the need to seek assistance. X X

Documents any and all unusual incidents with appropriate follow up action. X X Implements routine precautions and monitors aseptic techniques

and infection control practices. X X

Ensures bed/stretcher available prior to end of case. X X

Demonstrates ability to trouble shoot during equipment malfunctions

and seeks assistance if needed. X X

Calls for and checks blood products with RN, LPN or anesthesiologist according

Collaborative Care Guidelines for Perioperative Nurses